Clinical Reviewer

🔥 0 minutes ago

🌶️ New Mexico – Remote

🌶️ New Mexico – Remote

💵 $75k - $88k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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Comagine Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1973

🤝 Non-profit

🤝 B2B

🔬 Science

Non-profit • B2B • Science

Comagine Health is a national nonprofit health care consulting organization that partners with providers, payers, public agencies, community organizations and consumers to improve health care quality, equity, and outcomes. It offers systemwide quality improvement, care management, data solutions, research and evaluation, and COVID-19 response services, using health information exchange and health IT to inform public health surveillance and program design. Comagine focuses on supporting community health, behavioral health, and patient-centered initiatives through technical assistance, evaluation, and collaborative systems-level work.

📋 Description

• Assess the medical necessity and quality of healthcare services through utilization management reviews • Conduct prospective, concurrent, and retrospective utilization management reviews • Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual) • Consult with physician/practitioner consultants when services do not meet medical necessity criteria • Collaborate with internal teams and refer cases for additional review or escalation as appropriate • Refer cases to management when required • Provide clinical and utilization review subject matter expertise • Respond to provider, customer, and stakeholder questions regarding determinations and processes • Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information • Maintain accurate documentation and comply with all regulatory and contract standards

🎯 Requirements

• BA/BS in Nursing • Equivalent combination of education and/or related experience may be considered depending on contract • Minimum of 3 years of direct patient care (clinical) experience • Current, active, unrestricted RN license • Must meet New Mexico state and contract-specific requirements • Experience with InterQual Criteria • Strong proficiency in Microsoft Office Suite and familiarity with database systems.

🏖️ Benefits

• Medical, dental and vision insurance • Paid time off for vacation, illness, and volunteering • Retirement savings plan with employer contribution • Adoption financial assistance • Paid parental leave. • And much more!